Beyond Words Vol.4. No. 1. May 2016 Graduate School, Widya Mandala Catholic University
Surabaya, Indonesia The Pragmatic Awareness of Indonesian Nurses in Their Interactions
with Foreign In-Patients
Sapto Dwi Anggoro Stikes Hang Tuah Surabaya
Surabaya. Indonesia saptoanggoro@yahoo.com
Abstract
In hospitals, most nurses are responsible not only for caring but also building interpersonal relationships with their patients. Joint Commission International (JCI), nurses encounter foreign in-patients. This study investigated the ability of local nurses to communicate with English speaking patients in the hospital. Pragmatic awareness is the issue that becomes the focus to obtain better understanding on the nurses’ communicative aspects. It discussed how the nurses achieved successful or unsuccessful interactions in using therapeutic principles Audio recording, observations and interviews were used to see how their pragmatic awareness were applied in terms of of pragmatic principles and speech acts. The study also looked after the strategies used when unsuccessful communication with English speaking patients was solved. Some findings showed that the participants of the study could apply 11 out of 16 therapeutic communication techniques during their interactions with foreign in-patients. Meanwhile. 7 (seven) therapeutic techniques were not frequently used. In many cases the nurses avoid to apply some techniques because they were not confident their communication would be successful. A few techniques were reported to have difficulties and led to some misunderstandings. Most of the problems experienced by these nurses was triggered by languagebarrier, or their inability to formulate utterances that suited the constructions of therapeutic communication techniques. Pragmatic awareness was seen to be the major issue. It was indicated by some misunderstandings or pragmatic failure that the nurses made signalled by unexpected perlocutionary force by their foreign in-patients. Recommendations can be made in terms of language training concerning the strategies to formulate utterances in line with therapeutic communication techniques. Furthermore. nurses’ pragmatic awareness needs to be raised by improving language knowledge, especially the one dealing with pragmatic aspects. Subsequently it is recommended that the hospital allow language instructors to assist and monitor the nurses in case misunderstanding and other forms of communication problems occur. It is also important that every nurse is provided with a guide book that allows them to use it as a reference when unexpected miscommunication take place during the caring processes.
Keywords: pragmatic awareness, Indonesian nurses, foreign in-patients, therapeutic communication techniques
Introduction The issues of global village era have
brought great concerns to local businesses and services in Indonesia. Attempts of improvement are inevitable to business and service providers, including healthcare services. There have been increases in numbers of foreign patients who need medical treatments in some hospitals in
Surabaya. The presence of foreign patients in some hospitals, in some cases, has triggered some issues among health care practitioners. Among other problems related to foreign patients, communication is presumed to be the most serious problem among healthcare practitioners. It was reported that some nurses were in great
difficulties when they had to communicate with their foreign in-patients due to misunderstandings. It was also admitted by some nurses at a private hospital acquiring Joint Commission International (JCI) in Surabaya. They had communication problems with their foreign in-patients coming from varieties of countries that speak English in different manners. Based on these issues this study entitled “The Pragmatic Awareness of Indonesian Nurses with Their Foreign Patients” is expected to provide essential information concerning communication problems occuring between Indonesian nurses with their foreign in- patients.
The purpose of this study was primarily to investigate the ability of the local nurses to communicate with English speaking patients in the hospital. Pragmatic
awareness was the issue that became the focus to obtain better understanding on the nurses’ communicative aspects. The study discussed how the nurses could achieve successful interactions with their English speaking patients; how their pragmatic awareness applied to the application of pragmatic principles and speech acts; and how the nurses solved the problems in case of unsuccessful communication with English speaking patients. In hospitals, nurses are responsible not only for caring but also building interpersonal relationships with their patients. Examining nurse-patient conversations could have important implications for nursing practice and nurse education. Improvements in nurses’
communication skills could lead to better patient care, better outcomes, and hence better results for the society.
Literature Review The Nature of Nurse-Patient Communication
Traditionally nursing is viewed as a treating job for sick patients. In line with the global development in nursing, today nurses take some more roles rather than just caregivers. “Changes in nursing have expanded the professional nursing role to include increased emphasis on health promotion and illness prevention as well as concern for the patient as a whole. Among other roles, a nurse is expected to take the role of a communicator and educator (Potter and Perry. 2009 p.9)”. They are the front liners in hospitals, spending most of their time working to serve patients.
Communication is central to the nurse- patient relationship in hospitals. It covers interactions with patients and families, other nurses, health care professionals, resource persons and the community. The quality of communication is a critical factor in meeting the needs of individuals, families and communities. Without clear
communication, it is impossible to give comfort and emotional support, give care effectively, make decisions with clients and families, protect patients from threats to well-being, coordinate and manage patient care, assist the patient in rehabilitation, or provide patient education.
In many cases nurses communication strategies could lead to the success of nursing process. Chitty (1997) stated that nurses can achieve successful communication on most occasions if they plan their communication to meet four major criteria: feedback, appropriatenes, efficiency, and flexibility.
Effective nurses do not assume that they fully understand what the patients are telling them until they feed the statement back and receive confirmation. Feedback is meant to make sure that the information is correct.
For example, a nurse restatement saying, “If I understand you correctly, you have pain in
your lower abdomen every time you stand up.” The patient would then agree or correct what the nurse has said: “No, the pain is there only when I arise in the morning.” In this context, the nurse would accept the patient’s confirmation and treat it as the true state of the patient.
Appropriateness is related to the amount of message. When a nurse is required to give information, she or he should not speak less not more than it is required. If this condition is met, appropriateness is achieved. Thus, communication occurs accordingly. For example, if a patient asks, “When is my lunch coming?” The nurse, knowing that the patient has already eaten lunch, will be alert to other inappropriate messages by this patient that may signal a variety of problems, in this instance, the inappropriate message does not match the context.
Efficiency could refer to the use of simple and clear words that are timed at a pace suitable to participants. Messages must be adapted to each patient’s age, verbal level,
and level of understanding, for example, when a nurse explains to a five year old child that he is going to have a nebulae therapy the next morning. This message would not be efficient because the patient does not get any knowledge on that.
Flexibility is an aspect of communication that allows the speaker to be more adaptable. Flexible communicator bases messages on the immediate situation rather than preconceived expectations.
When a nurse student who plans to teach a patient about diabetic diets enters the patient’s room and finds her crying, she must be flexible enough to change gears and deal with the feelings the patient is expressing. Pressing on with the lesson plan in the face of the patient’s distress shows a lack of compassion as well as inflexibility in communicating. In line with this, Chitty (1997) insisted that the constant absence and ignorance of any of the four criteria can create disturbed communication and hamper the implementation of the nursing process.
Therapeutic Communication Technique When communication is incomplete, inappropriate, or absent, patients may experience fear and confusion that leads to increased risk to their safety (Peplau. 1952).
Nursing practice is equipped with a strong basis of communication skill. “Therapeutic communication promotes understanding that helps establish a constructive relationship between the nurse and the patient (Berman, Snyder, Kozier & Erb: 2008, p. 467).” Unlike the social relationship where a specific purpose or direction may be absent, the therapeutic helping relationship is patient and goal directed.
There are sixteen techniques of therapeutic communications. They are using silence, providing general leads, being specific and tentative, using open-
ended questions, using touch, restating or paraphrasing, seeking clarification, perception check or seeking consensual validation, offering self, giving information, acknowledging, clarifying time or sequence, presenting reality, focusing, reflecting, summarizing and planning (Berman, Snyder, Kozier & Erb: 2008, pp. 469-470).
Using silence. This technique refers to accepting pauses or silences that may extend for several seconds or minutes without interjecting any verbal response. Examples could be illustrated as a nurse sitting quietly (or walking with the patient) and waiting attentively until the patient is able to put thoughts and feelings into words.
Providing General Leads. Using statements or questions that (a) encourage
the patient to verbalize.(b) choose a topic of conversation. and (c) facilitate continued verbalization. Examples of providing general leads:
"Can you tell me how it is for you?"
"Perhaps you would like to talk about..."
"Would it help to discuss your feelings?"
"Where would you like to begin?"
"And then what?"
Being Specific and Tentative. Making statements that are specific rather than general, and tentative rather than absolute.
Asking broad questions that lead or invite the patient to explore (elaborate. clarify.
describe. compare. or illustrate) thoughts or feelings. Examples:
Rate your pain on a scale of 0-10."
(specific statement)
"Are you in pain?" (general statement)
"You seem unconcerned about your diabetes" (tentative statement), or "You don't care about your diabetes and you never will" (absolute statement).
Using Open-Ended Questions.
Asking broad questions that lead or invite the patient to explore (elaborate, clarify, describe, compare, or illustrate) thoughts or feelings. Open-ended questions specify only the topic to be discussed and invite answers that are longer than one or two words.
Examples of open-ended questions could be:
"I'd like to hear more about that."
"Tell me about.... "
"How have you been feeling lately?"
"What brought you to the hospital?"
"What is your opinion?"
"You said you were frightened yesterday. How do you feel now?" "I'd like to hear more about that."
"Tell me about.... "
"How have you been feeling lately?"
"What brought you to the hospital?"
"What is your opinion?"
"You said you were frightened yesterday. How do you feel now?"
Using Touch. Actively listening for the patient's basic message and then repeating those thoughts and/or feelings in similar words. This conveys that the nurse has listened and understood the patient's basic message and also offers patients a clearer idea of what they have said. An emphasis could be done by putting an arm over the patient's shoulder, of placing a hand over the patient's hand.
Restating or Paraphrasing. Actively listening for the patient's basic message and then repeating those thoughts and/or feelings in similar words. This conveys that the nurse has listened and understood the patient's basic message and also offers patients a clearer idea of what they have said.
Patient: "I couldn't manage to eat any dinner last night— not even the dessert."
Nurse:"You had difficulty eating yesterday."
Patient:"Yes. I was very upset after my family left."
Patient:" I have trouble talking to strangers."
Nurse:"You find it difficult talking to people you do not know?"
Seeking Clarification. It is a method of making the patient's broad overall meaning of the message more understandable. It is used when paraphrasing is difficult or when the communication is rambling or garbled. To clarify the message, the nurse can restate the basic message or confess confusion and ask the patient to repeat or restate the message.
Nurses can also clarify their own message with statements, e.g.
"I'm puzzled."
"I'm not sure I understand that."
"Would you please say that again?"
"Would you tell me more?"
"I meant this rather than that."
"I'm sorry that wasn't very clear. Let me try to explain another way."
Perception Checking or Seeking Consensual Validation. It is defined as a method similar to clarifying that verifies the meaning of specific words rather than the overall meaning of a message, e.g.
Patient: "My husband never gives me any presents."
Nurse: "You mean he has never given you a present for your birthday or Christmas?"
Patient:"Well—not never. He does get me something for my birthday and Christmas, but he never thinks of giving me anything at any other time."
Offering Self. It is used to suggest one's presence, interest, or wish to understand the patient without making any demands or attaching conditions that the patient must comply with to receive the nurse's attention. Or, providing, in a simple and direct manner, specific factual information the patient may or may not request. When Information is not known, the nurse states it and indicates who has it or when the nurse will obtain it.
"I'll stay with you until your daughter arrives."
"We can sit here quietly for a while; we don't need to talk unless you would like to."
"I'll help you to dress to go home, if you like."
Giving Information. This aims at providing, in a simple and direct manner, specific factual information the patient may or may not request. When information is not known, the nurse states this and indicates who has it or when the nurse will obtain it.
"Your surgery is scheduled for 11AM tomorrow."
"You will feel a pulling sensation when the tube is removed from your abdomen."
"I do not know the answer to that, but I will find out from Mrs. King, the nurse in charge."
Acknowledging. Giving recognition, in a non judgmental way, of a change in behavior, an effort the patient has made, or a
contribution to a communication. Acknow- ledgment may be with or without understanding, verbal or non verbal.
"You trimmed your beard and mustache and washed your hair."
"I notice you keep squinting your eyes.
Are you having difficulty seeing?"
"You walked twice as far today with your walker."
Clarifying Time or Sequence. It is carried out to help the patient clarify an event, situation, or event related to time.
Patient:"I vomited this morning."
Nurse:"Was that after breakfast?"
Patient: "I feel that I have been a sleep for weeks."
Nurse:"You had your operation Monday, and today is Tuesday."
Presenting Reality. This usually refers to a circumstance where a nurse helps the patient to differentiate the real from the unreal.
"That telephone ring came from the program on television."
" I see shadows from the window coverings."
"Your magazine is here in the drawer. It has not been stolen."
Focusing. This technique is meant to help the patient expand on and develop a topic of importance. It is important for the nurse to wait until the patient finishes stating the main concerns before attempting to focus. The focus may be an idea or a feeling; however, the nurse often emphasizes a feeling to help the patient recognize an emotion disguised behind words.
Patient:"My wife says she will look after me, but I don't think she can, what with the children to take care of, and they're always after her about something—clothes, homework, what's for dinner that night."
Nurse:"Sounds like you are worried about how well she can manage.
Patient:"My wife says she will look after me, but I don't think she can, what with the children to take care of, and they're always after her about something—clothes, homework, what's for dinner that night."
Nurse:"Sounds like you are worried about how well she can manage.
Reflecting. This technique was used when a nurse intended to direct ideas, feelings, questions, or content back to patients to enable them to explore their own ideas and feelings about a situation.
Patient: What can I do?
Nurse: What do you think would be helpful?
Patient: Do you think I should tell my husband?
Nurse: You seem unsure about telling your husband.
Patient: What can I do?
Nurse: What do you think would be helpful?
Patient: Do you think I should tell my husband?
Nurse: You seem unsure about telling your husband.
Summarizing and Planning. Such technique is commonly found when a nurse states the main points of a discussion to clarify the relevant points discussed. This technique is useful at the end of an interview or to review a health teaching session. It often acts as an introduction to future care planning.
"During the past half hour we have talked about... "
"Tomorrow afternoon we may explore this further."
"In a few days I'll review what you have learned about the actions and effects of your insulin."
"Tomorrow, I will look at your feeling journal."
Subsequently, tasks and skills required in each phase of helping relationship can be classified into four parts. They are the pre-
interaction phase, introductory phase, the working phase, and the termination phase.
Pre-interaction Phase. The nurse reviews pertinent assessment data and knowledge, considers potential areas of concern, and develops plans for interaction.
The required skills for the nurse include:
organizing data gathering, recognizing limitations as well as seeking assistance as required.
Introductory Phase. It could be accomplished in several steps. Opening the relationship is the first step. Both patient and nurse identify each other by name.
When the nurse initiates the relationship, it is important to explain the nurse's role to give the patient an idea of what to expect.
When the patient initiates the relationship, the nurse needs to help the patient express concerns and reasons for seeking help. The subsequent step is to clarify the problem.
Vague open-ended question, such as
"What's on your mind today?" is helpful at this stage because the patient initially may not see the problem clearly the nurse's major task is to help clarify the problem. The nurse activities involves attentive listening, paraphrasing, clarifying, and other effective communication techniques. A common error at this stage is to ask too many questions to the patient instead of focusing on priorities. The last step is in term of structuring and formulating the contract (obligations by both the nurse and patient).
Nurse and patient develop a degree of trust and verbally agree about (a) location, frequency, and length of meetings, (b) overall purpose of the relationship, (c) how to handle material confidential, (d) tasks to be accomplished, and (e) duration and indications for termination of the relationship.
Working Phase. This is the phase where a nurse and his/her patient
accomplishes the tasks outlined in the introductory phase, enhance trust and rapport, and developing care. This stage includes two activities: exploring thoughts and feelings, and taking action. The former requires the nurse to assist the patient to explore thoughts and feelings, and acquires an understanding of the patient. Meanwhile, the latter, insists on planning programs within the patient's capabilities and considers long-and short-term goals. The patient needs to learn to take risks (i.e., accept that either failure or success may be the outcome). The nurse needs to reinforce
successes and help the patient recognize failures realistically. The abilities required are decision-making, goal-setting, and reinforcement skills; as for the patient: risk taking is a common situation.
Termination Phase. Nurse and patient accept feelings of loss. The patient accepts the end of the relationship without feelings of anxiety or dependence. The skills required for the nurse in this stage is summarizing. On the part of the patient,he/she needs the ability to handle problems independently.
Pragmatic Awareness
A speaker of a particular language is considered successful when he/she could send an appropriate message by which a listener could react properly. In EFL settings, a speaker may or may not be aware of Pragmatic failure. J. Thomas (1983) defines pragmatic failure in Cross-cultural Pragmatic Failure as “the inability to understand what is meant by what is said.”
She points out that pragmatic failure may occur in any occasions “in which the hearer perceives the force of the speaker’s utterance differently from the speaker’s intent.” Pragmatic failure is possibly due to failure to express or interpret speaker- meaning or failure to observe cultural values.
Pragmatic awareness could be a fundamental issue in language use. Nikula (2002) stated that Pragmatic awareness is understood as a reference to features of language and interaction, with which language users orient to aspects of language use that pertain to its social and interpersonal functioning. It denotes a speaker’s competence to carry out successful communication. Raising pragmatic awareness can foster what Kramsch (1993: 236) calls ‘intercultural
competence’, where speakers of other languages can become aware of what she terms ‘the third place’. To add a definition of Pragmatic awareness Alcon and Jorda (2008) describes it as the conscious, reflective, explicit knowledge about pragmatics. It thus involves knowledge of these rules and conventions underlying appropriate language use in particular situations and on the part of members of specific speech communities.
Pragmatic Principles.
What may constitute the rules of speaker’s meaning is perhaps a more intense discussion in the field of linguistics.
Pragmatic proponents have provided theories to better understand existing phenomena underlying human communicative activities. Under the description of Mey’s term (2007)
“Pragmatic Principles” such linguistic behavior could be explained. The most relevant underlying theories include communicative, cooperative and politeness principles.
Communicative principle is proposed based on the fact that people talk with the intention to communicate something.
Communication does not always reveal
logic or truth but of cooperation. In this In this regard Leech added that when people speak they could intend to something beyond what they say. Communicative principle is essentially pragmatic since it suggests the language use emphasizes the users’ point of view in accordance to the available circumstances of context and speech.
Another aspect of Pragmatics suggests language users to participate in mutually accepted, pragmatically determined context.
As proposed by Grice (1975) cooperative principles consist of four pragmatic sub- principles, or maxims, i.e.: the maxim of quantity, quality, relation, and manners.
Maxim of quantity deals with the sufficiency of information being delivered.
In this phase one is required to make contribution as informative as required. In other words, he/she should not provide more information than necessary. Too much or too little information shared under certain circumstances would be considered as violations.
It is assumed that either following or violating the maxims could bring particular influences in communication. Those in favor of using cooperative maxims would develop good communication strategies.
Similarly, Mey (2001) stated that when we fail to use the maxims, communication would be difficult and possibly break down altogether.
Along with the development of Pragmatic issues, politeness strategy has become an important aspect of language use. It provides an understanding of how a language user can successfully communicate the language within the members of a society. To Watts (2003:39) politeness can be identified as follows:
1. Politeness is the natural attribute of a 'good' character.
2. Politeness is the ability to please others through one's external actions.
3. Politeness is the ideal union between the character of an individual and his external actions.
The concept of politeness is directed to language use which looks upon acceptability among the speakers of the language. This principle suggests that language should be acceptable regarding the contexts, showing respects among the language users as well as providing respectable interrelationship. To some extent this includes social aspects of communication. Much of what is said is determined by social relationship. Social distance is an indicator whether individuals have a close or a more distant relationship.
As the social distance between speakers increases, the greater requirement for polite use of language.” Addressing a boss
‘sweetheart’, for instance, is considered inappropriate and impolite, unless the boss and employee know each other well and over time have developed a close relationship. Thus it is clear that the words people use tend to as well as the topics they discuss are largely influenced by their social relationships, indicating whether they are disparate, equals, or intimates.
In general terms, politeness is relevant with ideas like being tactful, modest, and nice to other people. In the study of linguistic politeness is represented by the concept of ‘face’. “Some illocutions (e.g., orders) are inherently impolite, and others (e.g., offers) are inherently polite”
Leech (1983:83). In general giving orders could sound rude and demanding to the hearer. Hence, unexpected reactions are likely to emerge. Yet offers are always polite because the speaker seems to attend to the hearer’s favor. Mey (2007) argued that such concept might not apply without
regards for the contextual factors that define politeness in a given situation. This could be due to the social position of the speakers that may indicate different politeness values for individual cases. Another possibility is that politeness also depends on the positive or negative effects it has on the person who is given the order.
Politeness strategies could be categorized into negative and positive face.
In negative face, a speaker tends to display the need to be independent, to have the freedom of action, and not to be imposed on by others. Positive face, on the other hand, is the need to be accepted, even liked, by others, to be treated as a member of the same group, and to know that his or her wants are shared by others. Based on the natural way of interaction, a speaker could communicate in different ways. To get more acceptability in interaction, politeness technique could be applied. In general cases, direct messages tend to threaten face, whereas indirect messages have more acceptable responses.
Previously another proponent of Politeness principle set up some notions of politeness maxims. Leech’s view of politeness involves a set of politeness maxims analogous to Grice’s maxims.
Among these are (Leech, 1983:132):
Tact Maxim: Minimize cost to other.
Maximize benefit to other.
Could I interrupt you for half a second – what was the website address?
Generosity Maxim: Minimize benefit to self. Maximize cost to self.
Could I copy the web address?
Approbation Maxim: Minimize
dispraise of other. Maximize praise of other.
Mary you’re always so efficient – do you have copy of that web address?
Modesty Maxim: Minimize praise of self. Maximize dispraise of self.
Oh I’m so stupid – I didn’t make a not of that web address. Did you?
Agreement Maxim: minimize
disagreement/maximize agreement between self and other.
Yes, of course you’re right, but your decision might make her very unhappy.
Sympathy Maxim: minimize
antipathy/maximize sympathy between self and other.
I was very sorry to hear about your father’s death.
Speech Acts. In view of Pragmatics speech acts cover actual situations of language use. Mey (2007) states “Speech acts are verbal actions happening in the world.” This means uttering a speech act, a speaker does something with his/her words.
An utterance ‘You’re fired’ (Yule, 47:1996) indicates that someone will lose a job. When a boss produces such utterance to an employee, this will be taken as a true state by which he/she could no longer work for the company. The speech acts theory provides analysis for utterances in daily conversations. Back and Harnish (1979) stated that speech acts are a complex combination between utterances,
locutionary, illocutionary and perlocutionary acts. Among other discussions, Mey (2007) argued that illocutionary has been the focus of speech acts theory. A speaker’s intention could be understood by the illocutionary force that the hearer receives. Moreover perlocutionary act is accepted as a response of illocutionary force of an utterance.
Speech acts can also be either direct or indirect. A speech act takes a direct form if its intent is clearly conveyed by the words and structure of the utterance. ‘Take off your shoes’ is of course a direct speech act, taking the form of an imperative sentence
whereas ‘Could you take off your shoes?’, though takes an interrogative form, it functions as a request. Thus, the utterance is classified as an indirect speech act. “An indirect speech act is an utterance that contains the illocutionary force indicators for one kind of illocutionary act but which is uttered to perform another type of illocutionary act (Smith, 1991: 19)”.
Varieties of situations are available for the use of indirect speech act. A declarative used to make a statement is a direct speech act, a declarative used to make a request is an indirect speech act. Yule (2002:55) provided a number of examples as follows:
It's cold outside
I hereby tell you about the weather (direct speech act)
I hereby request that you close the door (indirect speech act)
Another possibility of the transfor- mation of direct into indirect speech acts
when a speaker wants hearer not to stand in front of the TV:
Move out of the way! (Imperative - direct speech act)
Do you have to stand in front of the TV? (Interrogative - indirect speech act) You're standing in front of the TV (Declarative - indirect speech act)
You'd make a better door than a window (Declarative - indirect speech act)
Yule (2002) also asserted that the use of indirect speech acts is mainly related to the speaker’s intention to show politeness in English. The desire to be polite also influences what kind of speech act one decides to use. Thus, one may choose an indirect speech act instead of a direct one in order to be more polite (Leech, 1983). The relationship between politeness and speech acts seems therefore very much similar to that between direct and indirect speech acts.
Methods Participants
The participants of this research were a male and two female Indonesian nurses from a Joint Commission International (JCI) accredited hospital in Surabaya. They were:
Nurse H, Nurse E, and Nurse R. They were chosen as participants of this study because they had the experience of treating foreign patients in the hospital for more than 2 years. They were undregraduate alumni of a nursing school where they had taken two English courses: General English and English for Nursing. They also scored fairly high for English proficiency test.
Subsequently, Four foreign in-patients were selected. They were: Mr. Dc, Mr.
Alex, Mr. Lv, and Ms. Rita. Mr. Dc was from Netherland, whereas Mr. Alex and Mr.
Lv were from The United States.
Meanwhile Ms. Rita were from Khazaktan.
They were all in Surabaya for work.
Data and Source of Data
The sources of data were verbal and non-verbal language uses in conversations and observation notes. The data obtained were verbal and non-verbal language uses, which correlated with the interactions of the local nurses and their foreign patients between the local nurses and their foreign patients. Irrelevant expressions were eliminated.
Several conversations sessions were carried out between the Indonesian nurses and their foreign in-patients. Mr. Dc was treated by Nurse H who was in charge of the caring processes. Mr. Alex and Mr. Lv were cared by Nurse E, and in the meantime, Ms.
Rita was taken care by Nurse R. Every language used by both the local nurses and their foreign in-patients was recorded and
transcribed. The conversations were extracted into several aspects of pragmatics, consisting of speech acts and pragmatic principles, applied in the nurse-patient interactions.
Additional source of data were taken from observation notes. Video recording was unavailable due to ethical issues. The presence of the researcher at the site where nurse-patient interactions took place was not admitted either. The observation notes were used, instead. However, the nurses and the foreign patients was aware of the study.
Research Instruments
As in many cases of qualitative research, the researcher of the study was the key research instrument. He played an important role in interpreting the data collected from the participants. As stated by Yin in Duff (2008) that the use of multiple sources of data could provide possibility to corroborate and augment evidence from other sources. McMillan (2008) added that instruments of data collection in case studies are mostly observation and interview.
Hence, in attempt to obtain sufficient evidence, the instruments applied were in terms of interviews and audio-recordings.
Interviews were conducted to discover some information on the part of the nurses.
The researcher formulated several question items so that nurses’ attempts in maintaining therapeutic communication with the foreign in-patients occurred. Considerations towards the strategies they used, and problems they encountered, were very essential in this study. The interviews were in the form of semi-structured interviews to allow the interviewer to compromise the form of open and structured interview (Richards, 2008).
In this way the researcher understood what topics need to be explored and formulated questions accordingly prior to the interviews. In spite of the carefully planned
scenario as characterized in structured interviews, during the processes the researcher treated the participants, in this case, the nurses in such a way that they had sufficient flexibility as characterized in open interviews.
Direct observation played an important role in this study. Analysis on pragmatic awareness should involve description on how meaning was delivered and perceived by the participants and their patients. In this respect Duff (2008) asserted that observation is necessary when one of the research objectives is to study linguistic performance. Interpretations on meanings frequently required verbal and non-verbal language behaviors, where the presence of the researcher could be crucial. In line with this Cowie (2008) defined observation as the conscious noticing and detailed examination of participants’ behavior in a naturalistic setting. In this study direct observation was very limited to ethical issues where the hospital only permitted the researcher to see the nurse-patient’s interactions outside the intervention processes that require the nurses to focus on the caring processes. However, observations were still carried out to help the researcher learned the atmosphere, situations and settings of the interactions. The observation notes were also treated as additional data for analysis.
Setting of the Research
The setting of the research was a private hospital in Surabaya acquiring JCI accreditation where foreign patients are mostly treated for medical assistance. The three participants of the study were involved in nurse-patient interactions taking place in in-patient wards. The research lasted for two months, lasting from August until October 2015.
Data Collection Procedure
In applied linguistics, data collection may include several instruments or techniques, as stated by Duff (2008).
Research instruments in this study included interviews and observation. Each of the instruments was used to collect data and provided relevant data for analysis.
Furthermore Duff (2008) also stated that data collection is adapted to accommodate underlying research questions and provide necessary answers for those questions.
Data collection was carried out in a number of phases. In order to gain access for further data collection, the researcher contacted the hospital management for a permit. The subsequent phase involved field observation regarding decisions on the schedules of data collection and appointment with the nurses to try out observation sheets and interview forms.
Revisions were made later on if there are necessary changes need to be made. At this stage the researcher also assembled key contact information and surveyed some data.
Several pre-interview sessions were also planned to learn and prepared strategies for deeper insights of the communication problems occurring during nurse-patient interactions. The nurses were asked questions about overall circumstances concerning their day-to-day interactions with their foreign patients. This helped the researcher to formulate more accurate interview items with the patients. Other description that was relevant was also collected during this phase.
In order that the interviews take place effectively, the researcher carefully carried out the semi-interview technique. Following Kothari (2004), he planned the interviews in advance and fully learned the problem.
During the interviews he acted informally
and friendly as well as established proper rapport with the interviewees so as to raise their motivation to communicate. It was indeed worth valuable data.
The subsequent phase in data collection was from nurse-patient interactions which were recorded. Due to ethical issue in the hospital, video-recording was not possible and audio-recorder was used instead. To obtain natural and genuine data from the patients, the nurses were instructed to record their conversations without prior consent.
When the conversation was finished, the nurses asked the patient for permission regarding the recording. If the patient agreed, the recorded conversations were accepted for data of the study. However, when the patient rejected, the researcher would delete the recording.
Since the researcher did not gain direct access to the patients, the observation was reported by the nurses through several interviews with the researcher. This technique was applied to provide answers to the related research questions regarding the situations in the wards and the associated contexts given in every interaction. It also applied to conditions when their patients experience communication difficulties during the caring processes. In this case the nurses acted as observers to find relevant data. In other word, direct observation was carried out throughout data collection phase.
Data Analysis Procedure
Data analysis in this study was generated from sources of data in terms of interviews, and recordings. From the interviews, the researcher took relevant data concerning the patients’ statement which correlated to the nurses’ ability to communicate and at the same time identified some communication problems.
Every utterance which was relevant to this
was taken as research data for further analysis. Data collection and analysis was carried out integratedly.
Data analysis procedure was carried out in line with the aspects of case study. In qualitative studies, data collection and analysis occur simultaneously and continuously, so it should not be considered as separate steps (Hood, 2008). The steps associated with both, data collection and analysis are adapted from Richards (2003) that started from collecting data in the forms of words and expressions produced by the nurses and their foreign in-patients. The data were then grouped according to the sequence of therapeutic communication techniques. The subsequent process of data analysis was carried out by putting all the selected words and expressions into their category corresponding to each therapeutic communication technique. In the next phase, words and expressions that highlight the success and failure of the nurse-foreign- in-patient communication were identified and eventually the last step of data analysis was to elaborate all pragmatic properties in justifying the success and failure of the nurses’ words and expressions.
Data analysis in this study was presented in accordance to the scenes in which the Indonesian nurses interacted with their foreign in-patients. Each of the scenes provided answers of each research question and consequently they covered the following items:
1. Situation and context
2. The strategies of speech acts
3. Degree of the Indonesian nurses’
pragmatic awareness/unawareness 4. The strategies used to overcome
unsuccessful communication
Situation and context were any circumstances that occured during the local
nurse-foreign inpatient interaction. The setting of interaction as the care-giving process administered including time, place, participant and the topic were discussed.
This was meant to provide more understanding towards meanings shared between the local nurses and their interactions. The researcher attempted to display any circumstances that may contribute to the interpretations of the local nurse-patients’ interaction. Any interactions occurring outside the therapeutic communication were not analyzed.
At the subsequent level of analysis, the researcher took some data relevant to the nurses’ pragmatic awareness. When misunderstandings took place, the points to which corresponded to the nurses’
unawareness were discussed. Misunder- standings were identified from the researcher’s perspective in case of the nurses’ inability to deliver messages to the patients properly. Misunderstandings in this sense could be identified from the nurses’
pragmatic failure that corresponds to the implications of Speech acts and other relevant pragmatic principles, such as:
Gricean maxims (1975): quantity, quality, relative and manner as well as politeness principles: tact, generosity, approbation, modesty, agreement and sympathy maxims Leech (1983).
The final stage of analysis was the description of collected data on the strategies when the nurses experience unsuccessful communication. When the nurses failed to express utterances as to instruct, give order, and persuade, they made use of certain strategies that brought meanings clearer to the patients. The use of any signs or attempts made to help communicate with their foreign patients were analyzed and described at this point.
Triangulation
Data triangulation was used in this study as data was taken from audio recording transcripts and interviews. Some data which were collected through audio- recordings somehow, did not provide clear information of what happened in the real- time conversations. Another thing was
unclear speech productions and background noise could be considered as distortions that could lead to misinterpretations. To avoid all those things, the researcher arranged some sessions of interviews with the nurses.
All their answers were then used to confirm the obtained information.
Findings and Discussion:
Nurse H
In this study, the nurse was involved in an interaction with Mr. Dc. His interaction was noted and analyzed in regards to the therapeutic communication techniques. It was found that in this study he used only three dominant techniques. They were in terms of: providing general lead, being specific and tentative and using open-ended questions.
In providing general leads, nurse H could apply some strategies that allow the patients to describe his feeling and find topic that seems to be the relevant issues to the patient. However, in many cases nurse H did not provide some leading statements like: “Alright,” “I’m listening,” “I see,”
and similar expressions by which the patient would be encouraged to continue his statements.
The subsequent therapeutic com- munication technique used by nurse H was being specific and tentative. In general, nurse H uttered closed questions to indicate something as specific or tentative until a feedback was given by the patient. Among various strategies, nurse H tended to specify uncertainty with closed questions, but she rarely produced narrow down information statements. Consequently, confusions occured frequently when nurse H formulated multiple questions.
In some conversations he asked more than one question at a very limited time without giving sufficient time for the patient
to answer one by one. As a result perlocutionary acts provided by the patients were not acceptable and missed the focus.
This could be subjected to committing violation in maxim of quantity. When a long information or question is used, it is less possible for the participants to arrive at mutual understanding.
The data indicated that in addition to general leads, nurse H was also in favor of using open-ended questions to obtain information. In doing so, he also used multiple questions to explore the patient’s problems. When two, or more, questions were asked in a row, only one was answered, usually the last. This was possibly due to insufficiency of time given to the patient. The nurse did not provide enough time for a pause so that the patient could take his turn before another question was formulated. Yet, only one was answered, instead of two as it was requirred.
It was the last question that normally got the answer, but the first was ignored. It was because the patient tried to keep up with the nurse’s pace. Again, it was assumed that nurse H violated the maxim of quantity and manner.
In every conversation, it is expected that a speaker should say or share information briefly and clearly. The problem appeared when the nurse violated the maxim. Another consideration should also be viewed from the perspective of tact maxim, where the speaker, in this case, the
nurse minimize cost to other and maximize the benefit to other. When these two maxims were violated, communication could be unsuccessful and misunderstanding was likely to take place.
Nurse E
Nurse E was in interactions with two foreign in-patients. They were Mr. Alex and Mr. Fernando. It was reported that she used eight therapeutic communication techniques during her interactions. She successfully performed four communication techniques in terms of: open-ended questions, restating or paraphrasing, offering self, and clarifying time or sequence. Apart from that, the four other techniques were found to be a little problematic.
In providing general leads, nurse E seemed to be familiar with situations where she was supposed to provide some variations to open topics for the patients. In some interactions she sometimes could make use of general leads when she sensed that the patients were curious about the progress in their caring processes. She was quite successful in using this technique.
There was no significant misunderstanding taking place as the nurse used general leads.
However, a minor problem could be noted for lacking of using fillers, such as: “yes”,
“then” and some other expressions. When she followed every information shared by the patient and indicated her presence, the patient would have explained more. The strategy of using fillers would then make the patients more active.
Though misunderstanding did not happen in providing general leads, nurse E received unexpected response as she was trying to start the conversation. “Are you busy?” was not typically a starter in nurse- patient interaction. It was supposed to begin with greetings and followed by questions or statements, directing the patient to say or
tell his conditions or if he had some pain or problems with mobility. Such problem was not necessary because the nurse had to be aware that nurse-patient conversation followed this pattern in most cases.
Moreover, this communication problem took place because the nurse violated maxim of relation, in which it requirred that the speaker and the hearer be consistant in making relation to the information being shared.
For nurse E specific and tentative statements were accepted as a way to trigger more information from the patients. When something was unclear, nurse E made sure of the precise information by using short questions which were tentative until it was confirmed by the patients. Applying this strategy, nurse E did not simplify questions so that they could be understood more clearly by the patient. Some problems appeared when the patient had to deal with complicated questions.
In being specific and tentative the nurse experienced a difficult situation. She was going to ask about the menu that the patient desired for lunch on the next day, before he was scheduled for discharge plan. In this case the nurse uttered “Tomorrow is already here before you go home. For lunch maybe?” The patient was confused because the question was very complicated. As a consequence, the perlocutionary act showed hesitation and misunderstanding. The message would have been answered correctly if the nurse had simplified the question. This problem could be considered as a violation of quantity maxim. For a successful conversation complicated questions should be simplified.
When patients stated unclear messages, the nurse was supposed to confirm or validate the information. One way to do it was through restating or paraphrasing. This
strategy was necessary to anticipate the loss of information at a certain degree and to reassure what was exactly meant by the patient. In some situations nurse E was capable of making restatements as they were intended to conclude and elicit emphasis on certain messages. Restating was also accepted as a strategy for an indication that a message was considered as well understood and clear.
In other situations, nurse E experienced difficulties understanding the messages from the patients. To some extent she did not understand the meaning of questions the patients asked. In order to seek clarification the nurse did not directly produce questions to discuss the points of confusion. Instead, nurse E restated the last part of the questions delivered by the patients that was actually an act of guessing. In general, this strategy did not help much and the patients continued asking with the hope that nurse E got the points of the questions. To anticipate greater confusion, nurse E tried using different words to find the expected information as intended by the patients.
In using the technique of seeking clarification, nurse E failed to deliver the messages effectively. As misunderstandings took place she was not supposed to use repetitions nor restatements too often because it was an act of violating quantity maxim, where messages should not be too lenghty. When the nurse sensed misunderstanding she should point out the problem and directly asked for an explanation. Otherwise, misunderstanding would be more serious and complicated.
Nurse E attended the patient for varieties of purposes, one of which was at the moment when she came to give information. A slight information was almost mistaken at the moment the patient asked for information regarding the cause of
his disease. When she provided information
“Maybe yes. But I think...” Actually the first statement was not correct but she did not directly say “No,” instead. The subsequent statement was the correction made by the nurse. She should avoid producing any statements that could potentially contribute to misperception. This was also considered as violation of quality maxim, requirring the speaker to be true.
Nurse R
Nurse R used six therapeutic com- munication techniques in her interactions with her foreign in-patient, Miss Rita.
Among other techniques she appeared to use: general leads, being specific and tentative, restating or paraphrasing, offering self, giving information, and clarifying time and sequence.
Nurse R has similar experiences with her colleagues, nurse H, and nurse E. In providing general leads she frequently started with questions as her other colleagues. She formulated broad questions to start conversations and fond out what was informed from the patient. However, in the analyzed data she appeared to use indirect speech act in her attempt to get information from her patient. Instead of using broad questions that generally signals of requesting information, she uttered a statement that also requiring the patient to provide answers. As she said “Yesterday you feel sick in the stomach”, the patient produced the correct perlocutionary act. She explained what problem she had at night.
To make specific and tentative statements, in one ocassion nurse R confronted difficulties that caused the patient fail to understand because she raised two questions and the patient only answered one. As she said “Still fluid or..? Did you have breakfast?” such questions were impossible to be answered at once.
Moreover the given answer was “a little”.
This was quite ambiguous because the answer could apply to any of these two questions. It was more complicated as the nurse did not discuss further about this misunderstanding. This problem was considered as violation of the maxim of manner.
Further in some interactions, nurse R was found to apply restating and para- phrasing technique. She was aware of a situation where sometimes the patient attempted to express ideas, and in return, restating or paraphrasing was requirred to show that the patients’ ideas could be accepted as true. When the nurse restated
“Ye, absorb for toxin”, the patient’s message was emphasized and the information was confirmed.
For most of the nurses, offering help to the patients was always done carefully. In offering self, nurse R carried out her job very well. In one situation she attended the patient when it was time to take the medicine. She said “There is four tablets for diarhea, protection your stomach. This is your glass.” The illocutionary act of such
expression was of course not meant to hand over an empty glass. This was actually a request, ordering the patient to immediately take the medicine and in case of troubles, the nurse was ready for an assistance.
The above discussion was to provide descriptions on the nurses’ pragmatic awareness in doing their therapeutic communication techniques. The analysis was based on the interactions they encountered with their foreign in-patients.
In such interactions, pragmatic awareness was not determined by how many therapeutic communication techniques they had performed but how well they elaborated their pragmatic knowledge in com- municating with their foreign in-patients.
Thus, the number of techniques applied by each of the nurses was not accepted as the indicator of the nurses’ pragmatic awareness. In one hand, one interaction may require only a few techniques and on other hand, more techniques were likely to be used, depending on the complexity of the topic and circumstances available at a particular interaction.
Conclusion Working with foreign in-patients
requires good communication skills. For Indonesian nurses, interactions with foreign in-patients could be accepted as a challenge because nurse-patient’s interactions should characterize therapeutic communication. In such communication every nurse is expected to contribute to the patients’
healing process through therapeutic communication techniques applied throughout the caring processes in the hospital.
From the analyzed data it was found that the three nurses participating in the study were aware of the application of
therapeutic communication technique in every interaction. Eight of the 17 therapeutic communication techniques studied in this research were frequently used. From the eight, four techniques, i.e., providing general leads, restating or paraphrasing, offering self, and giving information were used with less difficulties.
The other four techniques: being specific and tentative, using open-ended questions, seeking clarification, clarifying time or sequence, were experienced as difficult.
In every attempt to get accurate information, the nurses frequently made use
of questions which were specific and tentative. This technique was usually associated with strategies by which nurses triggered their patients were expected to provide more information, but in some interactions, the use of specific and tentative statements was not effective. This was because the nurses sometimes set up multiple questions in a row, and only the last question was answered to convey information requirred for medical records.
Confusion or misunderstanding was likely to occur due to this factor. The nurses were not able to maintain the flow of conversation that the patients were likely to skip a number of questions and end up giving very limited answer and even ambiguous statements.
Open ended question is another strategy to collect data from the patients. Many types of information can be explored when the nurses formulate open ended questions.
However, some investigations are not very effective when questions are not focused correctly. As what happens in using specific and tentative questions, the nurses occasionally produce unclear messages by proposing two different questions at once.
Open ended questions can be effective when the nurse gives sufficient time for the patient to provide answers, describe or explain in a detailed manner. With active listening, the nurses may also provide general leads, motivating the patients to discuss their problems more. When the nurses failed to apply this technique properly, information may not be shared adequately.
Misunderstandings were found in some situations. Among other techniques, seeking clarification was found to be the most difficult practice for most of the nurses.
When they were in the middle of misunderstanding, in most cases, they did
not use proper technique of seeking clarification. Instead of clarifying, they used tentative expressions and at different times they uttered restatements. As a rule, this technique suggested that having failed to clarify, they were expected to confess confusion and directly asked for an explanation.Thus, the risk of getting more serious communication problem could be minimized.
Some conversations indicated problems when the nurses were involved in interactions where clarifying time or sequence was required. They could not justify whether or not the accepted information was valid. For example, when a patient clarified his discharge time, the nurse was supposed to know in advanced that the patient was planned to leave the hospital in a given time. When the nurse failed to provide such clarification, the patients would later lose their trust in the nurses who were expected to be good resource persons.
Using silence and using touch were hardly observable during the study, but the nurses admitted doing so in almost every practice of the nurse-patient interaction.
Both techniques were reported based on the interviews. Using silence was very likely to occur in the beginning of conversations where nurses gathered data and information when they set up questions for the patients to answer. During that time, the nurses gave sufficient time for the patient to collect any information about symptoms, pain, and other related problems. In the meantime, using touch was used as a strategy for the nurse to show emphaty to the patient and build emotional relations as well as trust between nurses and patients. The nurses, in this case, admitted the use of this technique in times when they saw the patients encountering hard times.
Some strategies in therapeutic communication were not frequently practiced and the skills did not appear to be very familiar to the nurses. The most inactive skills applied in therapeutic communication were:
Perception checking or seeking consensual validation
Acknowledging
Clarifying time or sequence
Presenting reality
Focusing
Reflecting
Summarizing and planning
The nurses admitted that they felt inconfident to deeply interact in com- munication that required high command of English. They did not want to experience difficulties that ended up in mis- understandings. Some expressions were hard to formulate.
Inadequate skills in using English was a major problem for the nurses in communicating with foreign in-patients.
Moreover, pragmatic principles were given less attention due to the nurses incapabilities in elaboratin therapeutic communication skills and their pragmatic awareness.
Suggestion Therapeutic communication is a
compulsory curriculum, designed under the subject of nursing communication. In this subject, nursing students learn how to handle patients and improve their communication skill that should char- acterize therapeutic communication. They learn how to work and interact with patients at different levels of age, nursing processes, diseases, and unit of society (individuals, groups, families, and communities).
Training on therapeutic communication in English is necessary to encourage Indonesian nurses to provide better healthcare service and communication skill to foreign patients.
Attempts on raising language competence are needed to be made. Some of the results in this study have shown that unsuccessful communication depends on the nurses’ inability to predict patients’
responses regarding utterances they use to elicit the expected reactions. They failed to achieve the intended or produce perlocutionary forces.
To achieve this level of ability, nurses need to learn organizational knowledge, in which they elaborate grammatical and
textual knowledge. At another level, they also require pragmatic knowledge, in which functional and sociolinguistic knowledge are put into practice. This complex organization of language knowledge leads nurses to raise their pragmatic awareness.
Hence, language training should be managed in a way that it can adopt both therapeutic communication techniques and pragmatic principles especially in the field of speech acts.
In the future, nursing schools should provide a course in the curriculum that facilitates learning in real situations, requiring nurses to interact with foreign patients. Such course is not yet provided in the curriculum. As a matter of fact, hospitals in big cities, like Jakarta, Surabaya, Denpasar and other regions in Bali are visited by many foreigners who come for education, shopping, business, as well as recreation. They certainly need medical assistance in cases of accidents and other health problems.
It is expected that hospitals having regular visits of foreign patients make contributions to nursing schools in giving
